What Do You Do When Your Loved One Is Ill? The Line between Physician and Family Member

Conventional wisdom and professional ethics (13) dictate that physicians should avoid doctoring family members, emphasizing the potential for conflict of interest and lost objectivity. For example, the American Medical Association's Ethics Manual (3) states: Physicians generally should not treat themselves or members of their immediate families. Professional objectivity may be compromised when an immediate family member or the physician is the patient. Nevertheless, cross-sectional surveys have found that the practice of doctoring family members is commonplace (46). In a community hospital, 99% of surveyed physicians received requests from family members for medical advice, diagnosis, or treatment and 97% provided a service to family members (4). Few data on the quality of this care are available. A survey examining the processes of care for children of physicians found that although physician-parents had easier telephone access to pediatricians, they were less likely to call with concerns or come in for acute illness visits (6). Pediatricians estimated that physician-parents were more likely to wait inappropriately long before taking their children to be seen and that the patients' social or psychological problems were less likely to be addressed. In a carefully reasoned ethical perspective, La Puma and Priest (1) suggested 7 questions that physicians should ask themselves when considering whether to provide medical care for family members (Table). However, they proposed that the need to ask those questions does not apply to acute emergency care and care for most minor recurrent predictable illnesses, because in those instances care may be given by the physician in the family without overwhelming his or her objectivity or breaching ethical principles, and with much convenience to all concerned (1). This rule of thumb has risks, however, because emergencies are rarely convenient and predictable illnesses may still hamper a physicianfamily member's objectivity. Table. Questions Physicians Should Ask when Considering Providing Care for Loved Ones We review instances from our own experiences. In some cases, we regretted becoming involved in the care of our family members because we thought that involvement was not helpful and was possibly harmful, and in other cases, we thought our involvement was beneficial. We make recommendations to supplement the questions in the Table for how physicians might manage conflict between their professional and personal roles when a family member becomes ill. Although we focus here on physicians' involvement in family members' care, much of what we write and recommend could also apply to physicians' involvement in their own care (for example, diagnosing and treating themselves) (7, 8). Regretful Involvement Case 1: Dr. V. and His Wife My worst moment came last year, when my wife was pregnant. In previous years, we'd suffered through 3 miscarriages, and when she started spotting this time, we quickly came to terms with a fourth miscarriage. Actually, that's not entirely true. I remember it as my lowest moment in medicine, because I was ward attending and rounding with my team, which had been up all night with 12 patients. We were on rounds and I was being yelled at by a patient with chronic pain and a personality disorder when my wife called to tell me of her miscarriage. I couldn't believe that I had to be there at the hospital being berated for God knows what by a ridiculous overgrown adolescent while my poor wife was at home with her grief. That night, my wife complained of pain while I was trying to get to sleep. I half-heartedly examined her abdomen. I told her it was probably just cramping from the miscarriage, but she said the pain was different. I remember feeling overwhelmedand resentful. The next day, my wife made an appointment with an obstetrician she'd never seen before, borrowed a car, and drove herself to her appointment. Her obstetrician made the diagnosis of tubal pregnancy clinically, treated her with methotrexate, and ordered ultrasonography just to make sure. The obstetrician called us at home later that afternoon, chagrined to say that the size of the tubal pregnancy required surgery, and requested that we return that evening. The surgery went fine, thank goodness. To this day, I feel shame whenever I think of how I handled that situation. Any objective health professional would have thought about an ectopic pregnancy, but I wasn't being objective. It's not that I didn't think of it; I didn't think about anything. In my state of mind, I didn't want to think about anything. One reason why doctoring a family member is risky is because physicians lack the objectivity to evaluate and treat a loved one, as this case illustrates. Was the physician in this case doctoring his wife or avoiding doctoring her? His abdominal evaluation may have given both the momentary impression of doctoring, but the act was performed without the critical thinking and differential diagnosis that characterizes a professional encounter. The lost objectivity that renders physicianfamily members ineffective as physicians may also prevent them from recognizing that they are confusing their professional and personal roles. One way to prevent that confusion might be to ask the question: What would and could I do in this situation if I did not have a medical degree? In this way, the physician can assess whether he or she is crossing the lines between their roles and acting as a physician for a loved one. Although it may be tempting for a physicianfamily member to get involved when the problem is within his or her scope of expertise, it is not necessarily safer. Doctoring a family member with a familiar clinical problem may be more convenient, but we contend that physicianfamily members can realize most if not all of the benefit of getting involved by acting exclusively within their roles as family member and advocate. It may also be tempting for physicians to expedite or improve the care of a family member by pulling strings within the health care system. However, there may be unintended consequences to the physicianfamily member, patient, and treating physician if roles become confused, as illustrated by the following cases. Case 2: Dr. W. and His Wife During my residency, my wife had shoulder pains for which I took her to a sports medicine physician. He ordered a chest radiograph at the time, saying that sometimes intrathoracic problems can cause similar symptoms. He and I looked at the radiograph together and saw nothing. (Eight years later, a hot lamp on this overpenetrated radiograph would reveal a pneumothorax.) Three years later, my wife developed bilateral hernias and went in for surgical repair. I saw her off to the surgery suite and went to my office in the same hospital to await a call from the surgeon. When he called, he said that the surgery went fine, but chylous ascites leaked out of her abdomen when he made the incision. Ovarian cancer, I thought. Time stopped. What ensued was terrible. I told the surgeon that I would talk to my wife about it. I went to her bedside, sat by her, and held her hand. I told her that something was wrong, that she had ascites, and that I didn't know of any good things that would cause it. When the scan of her abdomen was performed, the radiologist called me to look at it with him. On the basis of what he saw, he thought it was a very rare disease called lymphangioleiomyomatosis. As before, I returned to the room, sat at her bedside, and told her the diagnosis. Her work-up confirmed the radiologist's suspicion. Looking back, I'm not sure why I thought I should be the one to deliver the bad news to her. I wish I had been on the other side of the bed listening with her to her doctors delivering the news. I wish I had been solely in the husband role that day, rather than putting on my doctor hat. It set us up for a lot of problems as we continued down that path for further work-up and treatment. In this case, Dr. W. became a physician to his wife in a way that added little to her care and that he later regretted. The wife's treating physicians also demonstrated confusion about their role and the husband's role in this case when they delegated their responsibilities to the willing husband. The case illustrates that role confusion may be greater when physician-patients and physicianfamily members seek assistance at the institution where they also work. The next case provides additional evidence for why important medical information should be delivered by a nonfamily member physician. Case 3: Dr X. and His Wife After my wife's first surgery and radiation therapy for a brain tumor, we planned a family vacation in Arizona to get away from things and to be together as a family. My wife had started her adjuvant chemotherapy, and repeated magnetic resonance imaging (MRI) was scheduled just before our trip, with her follow-up neurosurgery appointment after our return. I decided that I wanted to know the results of the MRI before we left so that I could be assured that everything was okay. I called the file room of the hospital in which the MRI was done, stating that I was Dr. X. and needed the results of the MRI. The reading, unfortunately, was that of a recurrence of the tumor despite the treatment my wife was receiving. I was devastated but knew that there was no sense in informing my wife or children because no change in treatment would be made until after our appointment with the neurosurgeon. I kept the information to myself so that my wife and children could enjoy the vacationas for me, I went and enjoyed what I thought would be our last vacation together. I learned a valuable lesson. Since then, I have refused to call for information about my wife or any of our children. I don't want to be their physician by giving them bad news (or good news, for that matter). I have since relied on appointments to get the information that we need at the same time that my l